AOPA, APMA urge CMS against new coding clarification

The American Orthotic and Prosthetic Association and the American Podiatric Medical Association have penned a joint letter to CMS urging it to reconsider a recent coding clarification regarding custom-fabricated diabetic inserts.

To bill Medicare for a custom-fabricated diabetic insert using HCPCS code A5513, the new clarification calls for practitioners to create a physical model of the patient’s foot and then use that mold to fabricate the insert. Any process that uses virtual models to create inserts, either through direct milling or other means, do not meet the standard, and instead must be billed using the code A9270, which describes statutorily non-covered services, according to a notice on the American Orthotic and Prosthetic Association (AOPA) website.

The letter, addressed to CMS Administrator, Seema Verma, MPH, expresses concern that the new clarification is overly strict and could limit the use of advanced technologies, such as direct milling and 3-D printing, both of which have the potential to provide patients with better-fitting inserts, according to the AOPA and the American Podiatric Medical Association.

“Unfortunately, the strict interpretation of the term ‘molded to patient model’ by the Durable Medical Equipment (DME) Medicare Administrative Contractor (MAC) medical directors forces manufacturers of custom-molded diabetic foot inserts to use less advanced technology in their fabrication process,” according to the letter. “The CMS continually stresses the importance of innovation through technology — we even have an annual Medicare fee reduction attributed as the ‘productivity adjustment’ underscoring the need to improve efficiency in ‘how.’ Eliminating access to this technology is not in the best interest of federal health programs or their beneficiaries.”

The notice refers to the clarification as “splitting hairs,” and argues that CMS is unlikely to see any savings from the new regulation, as annual Medicare costs for custom diabetic inserts are relatively small compared to the overall expenditure for the treatment of diabetes mellitus.

The two associations recommended that CMS instead instruct DME MACs and pricing, data analysis and coding contractors to be less restrictive in their interpretation of the A5513 coding language. Alternatively, the CMS HCPCS panel should change the language in the clarification to allow providers to bill custom diabetic inserts as A5513 without the requiring them to build a physical model, the associations said.